肛瘘诊治中国专家共识(2020版)

Consensus of Chinese experts on the diagnosis and treatment of anal fistula(2020)

肛瘘是结直肠肛门外科专业领域中最常见的疾病之一,多数为肛门直肠周围间隙脓肿破溃或引流后形成。由于其病理变化的复杂多样性,部分患者的临床疗效并不乐观,甚至可能出现严重的手术并发症,包括肛瘘迁延不愈或出现不同程度的排粪失禁等,明显影响患者生活质量,甚至导致残疾。中国医师协会肛肠医师分会临床指南工作委员会组织国内部分专家讨论编写本专家共识,建议在治疗前对肛瘘进行综合评估,包括详细询问病史、体格检查和必要的辅助检查。辅助检查包括瘘管造影、超声波检查、CT或MRI,目的在于准确判断肛瘘内口位置、瘘管走行方向及其与肛门括约肌的关系。腺源性肛瘘确诊后均需要手术治疗,手术方式可分为损伤括约肌的手术和保留括约肌功能的手术。前者包括肛瘘切开术、肛瘘切除术和肛瘘挂线术等;后者包括括约肌间瘘管结扎术、直肠黏膜肌瓣推进修补术、肛瘘激光闭合术和视频辅助肛瘘治疗术等。建议临床上根据患者具体病情选择或组合应用。生物可吸收材料包括肛瘘栓和纤维蛋白胶等,由于其具有保留括约肌功能和可重复应用等特点,亦推荐有条件和有经验的医生选择性应用。术后良好的伤口管理可以减轻患者痛苦,促进愈合,降低肛瘘复发率。由于肛瘘术后有一定的复发率和排粪失禁发生率,对部分病情复杂、反复手术和肛门功能已经受损的患者,在选择再次手术时一定要慎重,要权衡患者获益和排粪失禁风险。

Anal fistula is one of the most common diseases in colorectal and anal surgery.Most of them are formed after the abscess of perianal space reptures.Due to the complexity and diversity of pathological changes,the clinical efficacy of some patients is not optimistic,and there may even be serious surgical complications,including delayed healing of anal fistula or varying degrees of fecal incontinence,which significantly affect the quality of life of patients and even lead to disability.The Working Committee of Clinical Guidelines of Anorectal Physicians Branch of Chinese Medical Association organized some domestic experts to discuss and prepare this expert consensus.It is suggested that comprehensive evaluation of anal fistula,including detailed medical history,physical examination and necessary auxiliary examination should be conducted before treatment.Auxiliary examinations include fistulography,ultrasound,CT or MRI.The purpose of the auxiliary examination is to accurately determine the position of the internal orifice of the anal fistula,the direction of the fistula and its relationship with the anal sphincter.Adenogenic anal fistula needs surgical treatment after diagnosis.The operation methods can be divided into two types:operations breaching sphincter and operations preserving sphincter function.The former includes anal fistulectomy,anal fistulotomy and seton placement;the latter includes ligation of intersphincteric fistula(LIFT),rectal mucosal muscle flap advancement repair,anal fistula laser closure,video⁃assisted anal fistula treatment,etc.It is suggested to select or combine the application according to the specific condition of patients.Bioabsorbable materials include anal fistula plug and fibrin glue.Due to the characteristics of retaining sphincter function and reusability,it is recommended to be used selectively by qualified and experienced doctors.Proper wound management after anal fistula surgery can reduce the pain of patients,promote healing and reduce the recurrence of anal fistula.Because there is a certain risk of recurrence and fecal incontinence after anal fistula surgery,for some patients with complex condition,repeated operations or impaired anal function,we must be careful when choosing reoperation,and weigh the benefits of patients and the risk of fecal incontinence。